This application and checklist are for individuals or agencies who are prospective members. (This application and checklist are also required if membership haslapsed.) Please submit the completed application and the completed checklist by mail to: End Domestic Abuse Wisconsin, Attn: WBTPA, 1245 E. Washington Avenue, Suite 150, Madison, WI 53703.

You have the option of filling out either the Initial Application or a Renewal Application.

Initial Application: This application should be filled out for prospecting WBTPA members who are applying for theirfirstmembership or if there has been a lapse in time since their last WBTPA membership.

Renewal Application:This application should be filled out by WBTPA members who have maintained their provider status without any time lapse in membership. (Note: Renewal applicationswill beemailedto current members before the end of the membership year (which runs from May 1 - April 30).

WBTPA Membership:If your application is approved for membership, your name, batterers’ treatment program name, and your office contact information will be available on the WBTPA Listing Directory unless you indicate NOT to do so by checking the boxes in the application. The membership year runs from May 1st– April 30th. This application is valid for the May 1st, 2015 – April 30th2016 WBTPA membership year.

When you have updated that information, please fill out our application and email it towbtpamembership@endabusewi.org.You can also scan your proof of CEUs and email them in along with your application.

Optional:If you do not wish to fill out your application online, you can print it and either email the scanned version to wbtpamembership@endabusewi.org or mail it to:

EQUAL OPPORTUNITY AND LIMITED ENGLISH PROFICIENCY POLICYEnd Domestic Abuse Wisconsin: The Wisconsin Coalition Against Domestic Violence is an Equal Opportunity Employer and Service Provider. We do not discriminate on the basis of race, religion, color, disability, gender, sexual orientation, age or national origin. Free interpreter services are provided for people who are deaf or hard of hearing or who need language assistance to access services from the agency. These services are available by phone or in person. Privacy Policy